Healthcare Provider Details

I. General information

NPI: 1962515726
Provider Name (Legal Business Name): ELLEN GREENBERG M.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 PIERCE ST SUITE 214
KINGSTON PA
18704-5149
US

IV. Provider business mailing address

250 PIERCE ST SUITE 214
KINGSTON PA
18704-5149
US

V. Phone/Fax

Practice location:
  • Phone: 570-718-1760
  • Fax: 570-718-1763
Mailing address:
  • Phone: 570-718-1760
  • Fax: 570-718-1763

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberPS008060L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: